Healthcare Provider Details

I. General information

NPI: 1578327706
Provider Name (Legal Business Name): BRANDON L HUBERTY DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4214 FORTUNA CENTER PLZ
DUMFRIES VA
22025-1515
US

IV. Provider business mailing address

4417 MISSION AVE APT H102
OCEANSIDE CA
92057-6722
US

V. Phone/Fax

Practice location:
  • Phone: 571-402-2098
  • Fax: 571-888-8048
Mailing address:
  • Phone: 712-444-4107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number305565
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305217657
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: